Cleveland Clinic stroke study shows quick MRI helps cut down on unnecessary interventions, patients fare better

Once again clinicians are using the status quo rather than thinking about better and more objective ways to diagnose types of stroke. Maybe with the tricorder possibly thru one of these 17 ways.
http://www.cleveland.com/healthfit/index.ssf/2014/01/cleveland_clinic_stroke_study.html
Rapidly administering an MRI scan of the brain to patients who have had a stroke reduces by half the number of minimally invasive endovascular procedures they receive, procedures that are not always effective and can sometimes be harmful, according to a study published Thursday by researchers at the Cleveland Clinic.
Endovascular procedures to treat stroke, which involve delivering medication or removing clots via catheter, are commonly used to help restore blood flow to the brain when IV clot-busting drugs fail. While they can be helpful for some patients, the procedures also carry risks — including possible further damage to blood vessels and exposure to anesthesia — and have failed to show a benefit to patients in several large trials.
The Clinic’s study, published online in the journal Stroke, may have shown why, said lead author Dr. Shazam Hussain, head of the health system’s stroke program. Simply put, far too many people are being selected for the procedures based on incomplete information.
Most stroke patients are evaluated for endovascular procedures with a CT scan, he said, which can show bleeding in the brain “but unfortunately really isn’t able to tell you if there’s any damage to the brain due to a blocked blood vessel.”
“Those changes on a CT scan take several hours to appear,” he said. “So, you’re working on limited information.”
Using an MRI scan very soon after the stroke, on the other hand, will show such damage, and can help determine which patients are likely to benefit from endovascular procedures and those who have strokes so large that the techniques won’t be of use.
Dr. Jeffrey Sunshine, vice chair of radiology and an interventional neuroradiologist at University Hospitals Case Medical Center, said that the Clinic's study is "good work" that "helps confirm the benefit of advanced imaging before committing to surgery."
"The use of [endovascular therapy] went down, which isn't a bad thing," he said. "It's very expensive, it's very invasive, and we want to use it only when it will benefit people."
Stroke is the fourth-leading cause of death for Americans, and it is the leading cause of long-term disability, according to the Centers for Disease Control and Prevention. Almost 800,000 people a year will have a stroke, and about 130,000 people a year die from them in the U.S.
Many studies have shown that patients with large strokes tend to fare poorest, and a 2009 study of a small group of patients with large-volume strokes who subsequently underwent endovascular treatment showed that all had poor outcomes, including deaths, despite doctors reopening their blocked brain blood vessels.
"We know we can help certain patients and we know that for others it's futile," said Sunshine, who performs endovascular procedures. "We need to be able to separate these groups."
The Clinic changed its protocol for evaluating stroke patients in 2010 based on the   emerging data on stroke volume and outcomes, Hussain said. Clinic doctors dropped the CT scan and began using the “hyperacute” MRI, or an MRI scan administered as quickly as possible after the identification of a blocked brain blood vessel. For the study, they compared patients treated before the new protocol was put in place with those treated after.
They found that before changing the protocol, 85 of 88 patients treated received endovascular therapy, whereas after beginning to use the MRI scans only 92 of 179, or 51 percent, of patients went on to have one of the procedures.
Both those who did receive endovascular therapy after an MRI scan, and those who did not, tended to fare better than patients who were treated using the CT protocol — patients were three times more likely to be independent after 30 days in this group compared to the other, and the 30-day mortality rate was significantly reduced in comparison.
“I think there are a lot of stroke centers around the country that are interested in this information,” Hussain said, because it’s been unclear how best to treat stroke patients using the available therapies.
“Stroke is still a devastating disease and people continue to see it as something that not a lot can be done for,” he said. “We’re now focused on who are the best patients for the [endovascular] procedure, and will be very thoughtful in avoiding the therapy in people it could potentially harm.”